What is conservative kidney management?
Conservative kidney management (also known as conservative care or supportive care) is care to keep your kidneys working for as long as possible without dialysis.
"Conservative kidney management aims to delay progression of kidney disease and treat symptoms, but without replacing kidney function with dialysis," explains Professor Lucy Selman, Professor of Palliative and End of Life Care at the University of Bristol.
"It is about deciding that you won’t prepare for or use dialysis, and instead you want treatment to focus on helping you live as well as possible, based on how you want your remaining days to be. It is about continuing treatment that controls your symptoms and supporting and managing any problems that come up along the way, but not with dialysis."
Dr Anna Winterbottom, Senior Health Services Researcher at the Leeds Renal Unit, St James’s University Hospital, Leeds, and visiting Associate Professor at the University of Leeds, stresses that conservative kidney management still includes regular appointments with the kidney team (or sometimes with the GP), symptom control and dietary and lifestyle advice, all with a focus on maintaining quality of life.
"Conservative management is often framed as 'not doing treatment', however, it is in fact 'not doing dialysis' and there is continued support and treatment provided by the kidney team for people choosing this option," explains Dr Winterbottom.
"Some people on conservative care are also referred to a palliative care team, community nursing team, or hospice, meaning that additional support is provided."
Conservative kidney management: your questions answered
For some groups of people, such as those aged over 80, or those aged 65 plus who have other health conditions, or who are frail, the evidence suggests that dialysis provides very modest or uncertain benefits.
"In the majority of people with advanced kidney disease, dialysis extends life and can keep you well," explains Dr Heather Brown, consultant nephrologist at Guy’s and St Thomas’ NHS Foundation Trust. "However, in certain older people, especially those living with frailty or complex medical problems, this is not always the case."
"We also know that dialysis itself has the biggest impact on these groups – they have a larger burden of symptoms from it," says Professor Selman. "It negatively impacts their daily living and is associated with more dependency. A lot of the time you will be spending hours and hours every week in hospital. You have to weigh this up against the fact that it may or may not give you an extra few months. International guidelines say that you should be offered the choice of conservative kidney management alongside dialysis, and it can be a beneficial alternative."
Dr Winterbottom adds that it’s important for people with kidney failure to choose a treatment that fits best with their values and the way that they want to live their life.
"Dialysis involves regular hospital visits, multiple times a week, and includes a restrictive diet and fluid intake. It can impact on people's daily routines, their relationships, and quality of life. It can be a particularly burdensome treatment and may not extend a person's life expectancy for older adults or those with other health conditions."
"It is difficult to know exactly who will live longer with dialysis as the evidence is inconsistent, but we do know there is uncertainty about whether dialysis adds a survival benefit in certain patient groups including those over 80, or over 65 with frailty or other medical issues," explains Dr Heather Brown.
"We need to start talking about dialysis and conservative management in a more balanced way, considering the pros and cons of both," says Professor Selman. "We need to recognise that even if dialysis does confer a survival benefit of a few months in some cases, what will quality of life be like in those few months? If you want to be able to spend more time with your family and not be in a hospital, then you might be better choosing conservative management."
"Overall, when comparing dialysis and conservative care, you can expect to spend significantly more time in hospital in both outpatient and inpatient settings if you choose to have dialysis," explains Dr Brown.
"The focus with conservative kidney management will be on maintaining kidney function to maintain health and independence for as long as possible, to enable people to spend their later life doing the things they enjoy without the restrictions of dialysis, where it is uncertain dialysis will significantly extend life."
"It is not possible to say how long someone will live on conservative management: it does not actively replace kidney function and so life expectancy will be determined by several factors such as age, how fast the kidneys stop working, ability to do tasks and other illnesses," says Dr Winterbottom.
"Symptoms of kidney failure often occur very late in kidney disease and conservative management focuses on maintaining kidney function for as long as possible with good lifestyle advice and management of other medical conditions which may adversely affect function," says Dr Brown. "Many people with chronic kidney disease will die of other medical issues before developing any significant symptoms from their kidney disease."
"Conservative management is about symptom control," confirms Professor Selman. "There is no reason to think that your death experience will be distressing or difficult if you choose conservative management. In fact, the opposite is true, as we know that people who choose dialysis are more likely to die in hospital and many people would prefer not to do that."
Dr Winterbottom adds: "Kidney teams do everything that they can to try to manage people's symptoms and any pain experienced towards the end of life. During the last few days of life, people slip into a coma (fall unconscious), and when the toxins have built up in the blood, their heart stops beating and they die."
Support to help you make treatment decisions
Kidney teams support patients in managing their end stage kidney disease and deciding whether to have conservative kidney management or dialysis treatment.
"It is important that people choose a treatment to fit with their values and the way they want to live their life," says Dr Winterbottom. "Some people also find it useful to talk to 'peer supporters’ about their experiences of being on treatment. Having more information about the lived experience of a treatment can help people better understand how they might manage it in their own lives."
The Yorkshire Dialysis and Conservative Care Decision Aid summarises some of the factors you may want to consider when deciding whether to choose conservative kidney management or dialysis.
Discussing conservative management with family and carers
Family members and carers should be involved in decisions about treatment choice. "It can be really helpful for them to understand the benefits of each option, to help the person to make the correct treatment decision for them," says Dr Brown. "It’s also helpful for family and carers to understand the person’s wishes about further care so they can help advocate for their wishes in the future if needed."
"The family of the patient need to understand the pros and cons of both treatments," says Professor Selman. "This is especially important as there is evidence that how kidney clinicians communicate about treatment options tends to be biased towards dialysis, which can prevent patients from considering conservative care as a valid option for them."
"A diagnosis of kidney failure can impact on people's families regardless of which treatment option is chosen," confirms Dr Winterbottom.
"Dialysis is simply too much for some people to manage, and a person's kidney care team should be able to discuss this in more detail with the family. Understanding the similarities and differences in the aims of both treatments in a balanced way is important."